Excision External Ear

Question:

I did a partial excision of the left ear wedge with a layered closure. Can I code 69110 and a complex repair code since 69110 says “simple repair”?

Answer:

CPT 69110 includes the direct closure (bringing wound edges together) because it says “simple repair” so that would include a simple, intermediate or complex repair code. We would not recommend a separate repair code in the circumstance you describe.

*This response is based on the best information available as of 06/25/20.

Seroma after Breast Reconstruction

Question:

During the post-operative global period following breast reconstruction the patient presents with a seroma. Can I bill for the seroma excision and also bill for an office visit since it is a new problem?

Answer:

Medicare says treating the patient for issues related to the procedure, such as a seroma, are not separately payable unless they require a return to the operating room (modifier 78). There is not a modifier for “return to the office to treat a surgical complication.”

Check your other payors for their rules – in the absence of a specific payor rule allowing payment for treating complications in the office, we typically recommend you not bill. And, don’t forget, if you bill then the patient will have a co-pay.

*This response is based on the best information available as of 06/11/20.

Laceration and Fracture Repair

Question:

My physician is utilizing an open laceration on the patient’s chin for open reduction of a mandibular symphysis fracture and he wants to also charge for a complex laceration repair for that laceration. Is this billable or is it part of the ORIF code?

Answer:

If the fracture is repaired through the laceration then we code only the fracture repair – the laceration repair would not be separately reported.

*This response is based on the best information available as of 01/23/20.

Unspecified vs. Uncertain Behavior Skin Lesion Diagnosis Code

Question:

Can you refresh my memory on when to use the diagnosis code for skin lesion “uncertain behavior” vs “uncertain behavior”?  I know one is to be used before we get pathology results and one is for after, I just don’t remember which is which.  If you could give me the ICD10 codes that would be great too.

Answer:

You’ll use an “unspecified” diagnosis code when you do not have a final path report – D49.2 is for unspecified behavior lesion of the skin. Use the “uncertain” behavior diagnosis code when histologic confirmation whether the neoplasm is malignant or benign cannot be made by the pathologist.  Look up the path report diagnosis in the ICD-10-CM Index to if you have a path report.  Use D48.5 is for uncertain behavior of the skin.

*This response is based on the best information available as of 01/09/20.

Postoperative Incision Drainage

Question:

A patient had bilateral breast augmentation 5 weeks ago. She developed some drainage out of the lateral aspect of her left breast inframammary incision. The area was probed in the office with a Q-tip and it communicated with the implant pocket so I did a wash out of the left breast and replacement of the implant. We are charging the patient, not the insurance company, and my coder wants to use 19328 for the implant removal, 10060 for the washout, and 19325 for the new implant placement to determine our fee. I think my coder is unbundling and I should only charge my fee for 19325. What are your thoughts?

Answer:

I agree with you to use only 19325 for your fee comparison. The removal (19328) is included in the new placement (19325) because you couldn’t put a new implant in unless the old one was removed. Also, the wound washout would not be separately reported.

*This response is based on the best information available as of 10/31/19.

Removal of Breast Implant with Capsulectomy

Question:

My doctor specializes in breast reconstruction and has been asking me to bill 19328 (removal of intact breast implant) along with 19371 (capsulectomy) when he has to do a capsulectomy and remove the implant. It has come to my attention that this may be wrong and that 19328 is included in 19371. The CPT book is unclear and there is not a National Correct Coding Initiative (NCCI) edit between these two codes. So can I bill both?

Answer:

This is great example of where Medicare’s NCCI edits don’t reflect accurate coding. A CPT Assistant newsletter states “A capsulectomy (CPT code 19371) involves removal of the capsule. The implant is also removed and may or may not be replaced.” Therefore, CPT 19370 (capsulotomy) is included in 19328 when performed to remove the implant. CPT 19371 (capsulectomy) includes 19328 so both codes would never be reported for the same breast.

*This response is based on the best information available as of 10/17/19.